Introduction

Treatment of rectal cancer requires an understanding of presenting stage and therapeutic modalities to provide appropriate and effective multimodality approaches that are oncological sound and respectful in terms of organ preservation and survivors’ quality of life. Imaging (endoscopic ultrasound (EUS) and/or magnetic resonance imaging (MRI)) determines the locoregional staging and optimal treatment for rectal cancer patients. However, for pT1 rectal cancer usually arising into a locally resectable polyp, the yield and role of this diagnostic techniques are no well-established.

Aims & Methods

Aim: To describe the use of locoregional staging and analyze its yield in a pT1CRC state-wide population-based cohort of pT1 rectal cancers.
Patients and methods: Nation-wide population-based cohort, multicenter study (EpiT1Consortium), including 33 centers from 12 different Spanish states. All pT1 CRC cases diagnosed between 2007-2018 were included regardless of the treatment received. Exclusion criteria were: histology other than adenocarcinoma, cancer hereditary syndromes, inflammatory bowel disease, synchronous and metachronous colorectal cancer in the previous 5 years, metastatic neoplastic disease at the time of diagnosis. Information on the demographic of the patient, diagnosis, staging, treatment, complications and histology of pT1 as well as a minimum of 2 years follow-up were collected. Multivariate analysis was performed using binary logistic.

Results

From 3161 patients of the EpiT1 cohort, 681 pT1 rectal cancer with complete information on staging were included for the analysis. 424/681(62.3%) underwent staging: 234(55.2%) with MRI only, 131(30.9%) MRI and EUS, 59(13.9%) only EUS. The characteristics independently associated with the staging (MRI and/or EUS) were: location in lower/middle vs upper rectum (69.1% vs 30.9%; OR 2.8[1.7-4 .5]), suspicion of invasive carcinoma at baseline colonoscopy (64.8% vs 35.2%; OR 2.6[1.6-4.2]), high risk vs low risk histology (69.5% vs 30.5%; OR 2.4[1,3-4,2]), patient management by other specialist (surgeon, oncologist, MDT) vs gastroenterologist (82.7% vs 17.3%; OR 2.2[1.3-3.7]). T staging was correct with MRI in 54/191(28,3%) and with EUS in 69/117(59%) and considering staging by MRI or EUS, 67.1% of patients were over-staged for the T. For N staging considering MRI or EUS the sensitivity and specificity were 15.4% and 82.6%, respectively (Table 1).

Table 1. Diagnostic accuracy for N: in MRI+EUS, only MRI and only EUS

Conclusion

The limited yield of locoregional staging imaging techniques should be taken into account when choosing the therapeutic strategy of suspected/known T1 rectal cancers. For T staging, considering the high rate of over-staging with imaging modalities, a stepwise approach using histopathology from a local en-bloc resection as a first step seems reasonable. For N staging, a major effort has to be performed to increase the yield of staging modalities in clinical practice.

References

• Toes-Zoutendijk E et al. Gut. 2018 Sep;67(9):1745-1746​​

• Verseveld M et al. Eur J Surg Oncol. 2021 48 (2022):1153-1160​​

• Keys MT et al. Int J Epidemiol. 2021 Mar 3;50(1):143-155​

• ​Benson AB et al . J Natl Compr Canc Netw 2022​​

• Chan et al. Gastrointestinal Endoscopy 2019

Disclosure

No

Introduction

Eosinophilic esophagitis (EoE) is a Th2-related disease characterized by dysphagia and food impaction. EoE has been associated with several other atopic disorders, supporting the knowledge that it may represent a late manifestation of the so-called “atopic march”. However; in everyday clinical practice, allergic comorbidities are rarely objectivized by means of specialist consultations and often rely on patients’ self-reporting. This bears the risk of not fully recognizing the burden of Th2-related pathology, since EoE patients may outgrow some of the allergic diseases presenting during childhood; or, conversely, they could underestimate the presence and severity of Th2-diseases. To this aim, a multidisciplinary task-force involving multiple specialists was established at our university hospital, in order to systematically investigate newly referred EoE patients.

Aims & Methods

This is a cross-sectional observational study, involving consecutive EoE patients that were referred to our tertiary center from January 2022. We prospectively collected data about patients’ clinical history, specifically recording the presence of Th2-related comorbidities. Each patient underwent an esophagogastroduodenoscopy with differential esophageal biopsies. After reaching a conclusive diagnosis of EoE, patients were referred to dermatology, ear, nose and throat specialist (ENT) for rhinofibroscopy, immunologist (performing prick test, as necessary) and respiratory consultant for spirometry.

Results

40 EoE patients were included (34M, age 31±12 years), with a mean age of onset of 23±16 years. A clinical history of Th2-comorbidities was reported by 90% of the overall population with rhinitis being the most prevalent comorbidity (77.5%), while no patient reported Chronic Rhinosinusitis with Nasal Polyps (CRwNP). Asthma, food allergy and atopic dermatitis (AD) were reported in 15 (37.5%), 14 (35%) and 9 (22.5%) patients, respectively. Following the consultations, the presence of asthma, food allergy and AD did not significantly differ (37.5 vs 30%, 35 vs 45% and 22.5 vs 20%), since only 3 patients reporting a history of asthma did not confirm the diagnosis at spirometry and one patient with a history of AD had dermographic urticaria. On the contrary, following ENT consultation, 6 patients with rhinitis received the diagnosis of CRwNP (0 vs 15%, p=0.01). Overall, nearly 60% of patients had two comorbid Th2 disorders besides EoE and 25% of the whole population of EoE patients had 3 or more.

Conclusion

Our results clearly support the need for a multidisciplinary team approach to investigate the burden of Th2-related pathology in EoE patients. In our hands, the prevalence of Th2-related comorbidities was as high as 97.5% of EoE patients and up to 63% of our population had 2 or more allergic disorders. Furthermore, CRwNP is frequently under-reported and properly diagnosed only following rhinofibroscopy. This is further from being irrelevant when managing EoE patients. Indeed, it may guide the most appropriate choice of therapy by targeting multiple atopic manifestations at the same time, since many Th2-related diseases share common pathophysiological mechanisms and treatment.

Introduction

Residual colorectal neoplasia (RCN) after previous endoscopic mucosal resection is a frequent challenge. Different techniques are feasible including endoscopic full thickness resection (EFTR) with the FTRD system and Endoscopic submucosal dissection (ESD). We aimed to compare the efficacy and safety of both techniques for the treatment of those lesions.

Aims & Methods

All consecutive patients with a RCN treated either by FTRD or ESD were retrospectively included in this multicenter study. The primary outcome was the R0 resection rate defined as an En Bloc resection with histological free lateral and deep margins.

Results

A total of 275 patients (median age 70 years, 161 men) who underwent 177 ESD and 98 FTRD for RCN lesions were included among 19 centers. R0 resection was achieved in respectively 83.3% and 77.6% for ESD and FTRD (p=0.245). However, lesions treated by ESD were meanly larger compared with FTRD (p<0.001).The R0 rate in the ESD and FTRD group forlesions from 20 to 30 mm and 30 to 40 mm were respectively 83.9% and 57.1% and 93.6% and 33.3%. In multivariable analysis, ESD procedure was statistically associated with higher en-bloc and R0 resection rates after adjustment on lesion size (p=0.017 and <0.001). The adverse event rate was higher in the ESD group (12.1% vs 6.1%) due mostly to intra operative perforations.

Conclusion

ESD is effective to achieve R0 resection for RCN whatever the size and the localization of the lesions. When residual lesions are smaller than 20 mm, EFTR is an effective alternative.

Introduction

Endoscopy abnormalities of eosinophilic esophagitis (EoE) are currently graded based on the EoE endoscopic reference score (EREFS) ranging 0 to 9. Research has shown that esophageal biopsies are often omitted in Europe in patients reporting dysphagia when the upper endoscopy (EGD) shows no abnormalities [1]. However, a proportion of patients with eosinophilic esophagitis (EoE) may have normal endoscopy (i.e., EREFS=0), making the diagnosis more difficult and increasing the risk of diagnostic delay.

Aims & Methods

We investigated predictors of a diagnosis of EoE when the EGD is unremarkable (i.e., EREFS=0). Consecutive adult patients (≥18 years) with dysphagia who had EREFS=0 at an EGD with six esophageal biopsies were prospectively enrolled. All patients underwent EGD while off any eosinophil-depleting treatment. EoE with EREFS=0 was diagnosed based on the presence of at least 15 eosinophils/high-power field in at least one of six esophageal biopsies. When all six esophageal biopsies showed <15 eosinophils/high-power field, patients were diagnosed with non-EoE dysphagia (NED). Demographics, diagnostic delay (i.e., interval time between symptoms onset and diagnosis), esophageal symptoms, and atopic comorbidities (i.e., allergic rhinitis, asthma, eczema) were collected for all patients. Pearson's Chi-squared test and Fisher's exact test were used for comparisons. Odds ratios (ORs) were calculated to quantify associations between disease states. Significance threshold was set at p<0.05.

Results

Of 133 included patients, 51 (38%) had NED, while 82 (62%) had EoE with EREFS=0. Patients with EoE were more commonly males (67% vs 35%; p<0.001) and younger (37 vs 46 years; p=0.005) compared to patients with NED. Patients with EoE were diagnosed with a significantly longer diagnostic delay than NED (28 vs 4 months; p<0.001). Heartburn, regurgitation, chest pain and dyspepsia had similar prevalence in the two groups. In contrast, patients with EoE had a significantly higher prevalence of atopic comorbidities compared to NED (83% vs 39%; p<0.001).
The presence of rhinitis, diagnostic delay longer than 12 months, any atopic comorbidity, age younger than 37 years, and male sex were associated with an increased risk of EoE with OR of 47.0, 11.6, 7.4, 3.8, and 3.7, respectively (p<0.01 for all).

Conclusion

EoE remains a possible diagnosis in patients reporting dysphagia even when endoscopy is normal. The presence of rhinitis and longer diagnostic delay, the presence of any atopic comorbidity, and younger age are associated with a diagnosis of EoE and are helpful to raise the suspicion of EoE and prompt endoscopists to collect esophageal biopsies.

References

[1] Tourlamain, G., Garcia-Puig, R., Gutiérrez-Junquera, C., Papadopoulou, A., Roma, E., Kalach, N., Oudshoorn, J., Sokollik, C., Karolewska-Bochenek, K., Oliva, S., Strisciuglio, C., Bauraind, O., Auth, M. K., Thomson, M., Otte, S., Rok, O., Dias, J. A., Tzivinikos, C., Urbonas, V., Kostovski, A., … ESPGHAN EGID Working group (2020). Differences in Management of Eosinophilic Esophagitis in Europe: An Assessment of Current Practice. Journal of pediatric gastroenterology and nutrition, 71(1), 83–90. https://doi.org/10.1097/MPG.0000000000002672

Introduction

Gastric cancer (GC) incidence based on the endoscopic Kyoto classification of gastritis has not been systematically investigated using time-to-event analysis. Therefore, we examined GC incidence in an endoscopic surveillance cohort.

Aims & Methods

This study was retrospectively conducted at the Toyoshima Endoscopy Clinic. Patients who underwent two or more esophagogastroduodenoscopies (EGDs) were enrolled. GC incidence was based on Kyoto classification scores, such as atrophy, intestinal metaplasia (IM), enlarged folds (EF), nodularity, diffuse redness (DR), and total Kyoto scores. Atrophy was classified using the Kimura-Takemoto classification. Non-atrophy and Closed I, Closed II and III, and Open I to III were scored as atrophy scores of 0, 1, and 2, respectively. IM scores of 0, 1, and 2 were defined as the absence of IM, IM limited to the antrum, and IM extending into the corpus, respectively. The absence and presence of EF were scored as 0 and 1, respectively. The absence and presence of nodularity were scored 0 and 1, respectively. DR scores of 0, 1, and 2 were defined as the absence of DR, mild DR and/or DR with partial regular arrangement of collecting venules (RAC), and severe DR without RAC, respectively. The endoscopists diagnosed the Kyoto classification scores on-site during the index EGD. Hazard ratios [HRs] adjusted for age and sex were calculated using a Cox hazard model. This study was approved by the institutional review board of the Yoyogi Mental Clinic (approval no. RKK227).

Results

A total of 6718 patients were enrolled (mean age 55.0 years; men 44.2%). Of them, 3754, 2264, 700 patients were in H. pylori uninfected, eradicated, and currently infected status, respectively. Patients were followed up for up to 5.02 years. The mean Kyoto classification scores for atrophy, IM, EF, nodularity, DR, and total Kyoto were 0.585, 0.284, 0.039, 0.026, 0.312, and 1.247, respectively. During the follow-up period, 37 GCs occurred in 34 patients. All GCs were superficial and within the submucosal depth. Lauren’s intestinal type made up 89.1% of GCs. The annual incidence rates of GC were 0.04%, 0.17%, and 0.73% for atrophy scores of 0, 1, and 2; 0.07%, 0.25%, and 1.10% for IM scores of 0, 1, and 2; 0.17% and 0.92% for EF scores of 0 and 1; and 0.06%, 0.55%, and 0.74% for DR scores of 0, 1, and 2, respectively. The annual incidence rate of GC was 0.19%. The GC incidence rates were 0.05, 0.07, 0.47, and 1.27%/year for the total Kyoto scores of 0-1, 2-3, 4, and 5-8, respectively. Multivariate analysis showed that Kyoto atrophy scores 1 (HR with score 0 as reference: 3.66, 95% confidence interval [CI]: 1.06-12.61), 2 (11.60, 3.82-35.27), IM score 2 (9.92, 4.37-22.54), EF score 1 (4.03, 1.63-9.96), DR scores 1 (6.22, 2.65-14.56), and 2 (10.01, 3.73-26.86) were associated with GC incidence, whereas nodularity scores were not. The total Kyoto scores of 4 (HR with total Kyoto scores 0-1 as reference: 6.23, 95% CI: 1.93-20.13) and 5-8 (16.45, 6.29-43.03) were more likely to develop GC, whereas the total Kyoto scores 2-3 were not, as shown in table. The HR of the total Kyoto score for developing GC per 1 rank was 1.75 (95% CI: 1.46-2.09, P<0.001).

Conclusion

A high total Kyoto score (≥ 4) was associated with GC incidence. The endoscopy-based diagnosis of gastritis can stratify GC risk.

Disclosure

All authors disclosed no personal conflicts of interest.